Pelvic prolapse student


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Pelvic prolapse student

  1. 1. Pelvic Floor Dysfunction Khalid Sait FRCSC Professor ( Gynecological Oncology) Faculty of Medicine King Abdulaziz University
  2. 2. Normal Pelvic Anatomy
  3. 3. Pelvic anatomy n  Ligament: connect two bone n  Tendon: connect bone to muscle n  Mesentery: fold of peritoneum contain vessels, nerve and lymphatic n  Fascia: connective tissue surround two muscles n  Pelvic bone: fixed landmark
  4. 4. Pelvic floor Support n  Passive Support: Pelvic Bone Endo pelvic fascia n  Active Support: Pelvic muscle
  5. 5. Endopelvic fascia n  Uterosacral ligament n  Pubocervical fascia n  Rectovaginal fascia n  Urogenital diaphragm
  6. 6. Pubocervical fascia n  Extend between the two isch spine at level of cervical ring and laterally inserted at the white line which is the arcus tendenus
  7. 7. Rectovaginal fascia n  Extend between the two isch spine at level of cervical ring and laterally inserted at the white line which is the arcus tendenus
  8. 8. Uterosacral ligament n  From S1and S4 to the back of cervix at level of cervical ring
  9. 9. White Line arcus tendenus n  Is condensation of fascia at the lavator ani muscaly that extend from isch spine to the back of sympesis pubis at the level of pubic tubercal n  Its detachment cause paravaginal defect
  10. 10. Urogenital diaphragm n  Condensation of the fascia of: n  Ischiocavernosus n  Bulbocavernosus n  Deep transverse pernieal muscle
  11. 11. Pelvic floor Muscle n  Levator ani muscle 1- Pubovisceral muscle Hammock muscle ( u shape muscle) sling like arrangement Include puboccygeous and puborectalis 2- Iliococcygeous muscle Triangle muscle n  Coccygeus
  12. 12. Pelvic support n  Not important in pelvic support: Urogenital diaphragm Superficial perineal muscle Bulbocavernosus muscle Round ligament Broad ligament
  13. 13. DeLancey levels of vaginal support n  Level I suspension: uterus and vagina vault utrerosacral n  loss of this support result in vaginal and uterine prolapse n  Level II: attachment bladder and rectum pubocervical and rectovaginal fascia) (loss of this support result in cystocele and rectocele n  Level III Fusion diffuse to perineal body
  14. 14. Pelvic Organ Prolapse (POP) Protrusion of the pelvic organs into, or out of, the vaginal canal
  15. 15. Pelvic Organ Prolapse (POP) n  Central/Apical: Uterine /Vault Prolapse n  Anterior: Cystocele / Urethrocele n  Posterior: Rectocele/Enterocele
  16. 16. Pubo-cervical fascial defect Richardson
  17. 17. Uterine prolapse n  First degree: descend below ischial spine not reach introits n  Second degree : cervix visible at introits n  Third degree: procidentia the whole uterus is out side the introits
  18. 18. Tetralogy of “Fall-out”
  19. 19. Assessment Bump 1998
  20. 20. Epidemiology of POP n  Life time risk of developing POP: 11.1% n  13% of hysterectomies in all ages n  Most common reason for hysterectomy in women > 50 Olsen 1997, Allard 1991
  21. 21. Epidemiology of POP Post-hysterectomy vault prolapse (PHVP): n  11.6%: hysterectomy for pelvic prolapse n  1.8%: hysterectomy for other benign disease Marchionni 1999
  22. 22. Etiology & Contributing Factors
  23. 23. Etiology & Contributing Factors n  Childbirth n  Congenital weakness of fibro muscular support ( white > black) n  Aging / Estrogen deficiency n  Increased intra-abdominal pressure n  Repetitive pelvic pressure (Lifting or Coughing) n  Neurological disease (eg. Spina bifida) n  Connective tissue ( eg. Ehlers-Danlos syndrome)
  24. 24. Damage to pelvic support n  Neuromuscular damage n  Connective tissue damage
  25. 25. Symptoms and Signs n  A symptomatic n  Heaviness / full feeling in the pelvis n  Some thing coming down n  Lump in vagina n  Urinary symptoms( up to anuria) n  Difficult in defection n  Difficulty in walking n  Vaginal discharge and bleeding n  Dysparonia ( the muscle are slack) n  Vagina flatus ( whoopee cushion)
  26. 26. Management of POP
  27. 27. Management n  Treat underlying cause n  Conservative: Kegal /Passaries n  Surgical
  28. 28. Kegal Exercise n  Find the right muscle: Lavator ani muscle (Hammock muscle/Triangle muscle) 1- stop the flow of urine 2- stop passing gas 3- squeezes your finger in vagina n  How frequent you do n  Repeat but don't overdo it
  29. 29. 1.  Obliterative (colpocleisis) 2.  Reconstructive Ø  Abdominal/laparoscopic: o  Para-vaginal repair Ø  Vaginal: o  Anterior colporrhaphy o  Graft interposition o  Para-vaginal repair Ant. POP: Surgical management
  30. 30. Anterior colporrhaphy: Procedure
  31. 31. Paravaginal repair: Procedure
  32. 32. 1.  Obliterative (colpocleisis) 2.  Reconstructive (vaginal): n  Posterior colporrhaphy (+/- perineorrhaphy) n  Graft interposition n  Site-specific repair Post POP: Surgical management
  33. 33. 1.  Obliterative (colpocleisis) 2.  Reconstructive Ø  Abdominal/laparoscopic n  Colpo-sacropexy n  Uterosacral suspension Ø  Vaginal: o  Sacro-spinous vault suspension o  Iliococcygeus suspension o  Mayo/McCall culdoplasty Apical POP: Surgical Management
  34. 34. Principal of repair
  36. 36. Lefort